Here is a question to Dr. Ostiguy. Let's say I am a smoker, and I come to your smoking cessation clinic and tell you that I really want to quit, that I've had it with smoking. You said in your presentation that it takes more than willpower. I have the willpower, but obviously I need more.

What would you suggest I do: go with a nicotine patch or go with an e-cigarette? What do you tell your patients?

The first thing is to find out what you have tried in the past. Most people have tried many different things in the past. We have to build on that experience.

Now, we have to also assess how addicted you are. Are you a hard-core smoker or a light smoker? If you're a hard-core smoker, we have to assess this. It could be assessed by the number of cigarettes you smoke, and of course, in a clinic such as ours we measure the nicotine level in the blood, which is a much better way of assessing the amount of dependence a person has.

Then we discuss with the patient what they would like to start with. Usually we would start with pharmacotherapy approved by Health Canada, nicotine replacement therapy. It's only recently that we have seen advertising recommending combined nicotine replacement therapy. We've been using this for 15 years. The patch does provide a level of nicotine, which is very low and doesn't give the kick that a smoker gets from a cigarette. You need a way of delivering nicotine that will go to your brain much faster than by any of these devices, so we have to use combined therapy.

I had a patient with severe emphysema. He was unable to climb the six stairs coming up to the clinic. He was admitted two or three times a year for COPD exacerbation. He was using his action plan every month. We gave him Champix, we gave him patches, we gave him nicotine gums, we gave him bupropion, and all of them were failures.

He decided to buy an electronic cigarette. After one year, his concentration of nicotine in the electronic cigarette was down to three milligrams per ml. He was not admitted for any COPD exacerbation and he didn't use his action plan, except for once during that winter, and since he had a construction business, he converted a room in his house into a gym.

I could tell you success stories like this time and time again, but there's not one way of approaching; this is the sort of thing we have to discuss with the patient. Unfortunately, we don't have what they have in Europe. Each hospital should have a good smoking cessation clinic that can address these cases of hard-core, addicted smokers.,

I presume that you're aware of this study coming from the Mayo Clinic saying—and the government pays for that—that people buying nicotine patches at the pharmacy without any counselling had the success rate of quitting smoking lower than the ones who quit by themselves cold turkey. You literally need coaching and counselling.

There are a number of factors that would have contributed to declines. It's not just plain packaging. There are other measures in place as well. The Australian authority, the health department, concludes that plain packaging was one of the factors that has contributed to the decline in prevalence.

It is always very interesting, of course, and it is difficult to satisfy everyone and to come up with a solution that addresses all the problems. I was wondering about the stores that sell vaping products.

Like my colleague opposite, Mr. Webber, I do not smoke. So I do not go to those stores to buy cigarettes. Do they sell nicotine patches there? Do they sell products to help people stop smoking? Having said that, I doubt it.

You talked about support for people who want to stop smoking. If they do not have medical support, or at least some professional support, they have significantly fewer chances of success. The problem with e-cigarettes with nicotine is that they are generally and easily accessible on shelves. If e-cigarettes were sold in pharmacies, by health professionals who could follow up with those who buy them, then it would be possible to see the evolution of the treatment and, subsequently, to improve the situation.

Those products are on the market. Since 2009, Health Canada has said that those products are not permitted without the submission of a proposal that would result in approved therapeutic products. No one has submitted such a document. Even though those products are less dangerous than cigarettes, they do not reach the “therapeutic” threshold according to the Health Canada standard. If we made the products legal through Bill S-5, we would sort of create a third route between illegal products and therapeutic products approved by Health Canada.

On the economic front, we are talking about contraband and prices. If we draw a parallel with the legalization of marijuana, there is the whole issue with the price of the product. That's what makes contraband come into play or not. In this sense, it becomes advantageous for a regular smoker, who spends several thousand dollars a year anyway, to use contraband. If the price of cigarettes goes higher and higher, it is a damper for a certain segment of the population. However, for people who are regular consumers, it is advantageous to get contraband and encourage that market.

Price increases are the most effective way to reduce consumption, especially for teenagers, who do not have a lot of money for that.

In Canada, there is smuggling, but it is more prevalent in Ontario and Quebec, where taxation is lower. In the west and the Atlantic, contraband is much less significant, not necessarily because of high taxes. Illegal factories and proximity to urban centres, such as Toronto, Montreal and various parts of southern Ontario, encourage smuggling.

There are measures we could use to fight smuggling. We have recommendations for Ontario and the federal government. We could do it at the same time.

Dr. Ostiguy, what warnings or cautions do you believe should be labelled on nicotine vaping products? You indicate that you feel they must be regulated but that availability must not be made more difficult than for buying tobacco cigarettes. What cautions or warnings would you advocate for on vaping packaging?

It should be said that nicotine could become addictive; this is something to be careful about. This is about the only concern I would have about the electronic cigarette.

Again, I wish people would pay more attention to the studies coming from England and Europe saying that among those who have never smoked, it's very unusual for youngsters to take up electronic cigarettes. In electronic cigarettes, the addictiveness of the nicotine is not as strong as with tobacco cigarettes, because although nicotine is addictive, with the tobacco cigarette you have all the constituents of the tobacco that make it more addictive—the pH, the flavour, the chemical additives, such as menthol and that sort of thing. Yes, nicotine could be addictive; coffee is also addictive. However, with electronic cigarettes, the addictiveness is less than with tobacco cigarettes.

In my experience, when the heavy smokers, the addicted smokers, decide to buy an electronic cigarette, very often people want them to stop from one day to the next. That's not the way. They go down; they start with 18 milligrams and then they go to 15, 12, 9, 6, and then to zero. We have to be patient. It might take a year or a year and a half to do so, but we have to be patient and give proper follow-up and counselling.

Mr. Chair, I'd like to go on the record as saying that I've never tried smoking a single cigarette. When I was 12, my father offered me $100 if I made it to the age of 18 without smoking a cigarette. It worked. I plan on doing the same with my family.

Dr. Ostiguy, I have another question. You mentioned that it has sometimes worked that your patients moved from cigarette smoking to e-cigarettes. Have you seen or could you perceive a trend in young people whereby they move from e-cigarettes to smoking? Do you see this as a possibility, or is there an increased risk or threat of it?

I don't see it in our clientele. Of course, we're dealing with an adult clientele.

An excellent review was issued last week in the most recent document from Public Health England about the gateway effect that people were talking about. It's very difficult to make a good, sound, scientific interpretation of all this data, because it's been studied in different ways using different questionnaires, but the British experience is firm about saying that the electronic cigarette is not adopted by those who have never smoked. It's fewer than 1%.